Comorbidity

Coexisting or comorbid features are common in patients with first-episode psychosis and are associated with worse outcomes. Alcohol and drug abuse are common, occurring in up to 70% of cases [46,47].

Substance use should be assessed, including a description of the type, amount, frequency and method of use, the reasons for use and the effects of use, particularly during the time that psychotic symptoms started to develop. Patients' attitudes towards substance use and their motivation to cease should be explored. Patients tend to deny substance use initially, but then give more accurate accounts as they start to recover. Urine drug screens can provide a more objective assessment. Patients and families may focus on substance use as a less stigmatizing explanation for the psychotic episode.

Disorders that are less commonly associated with early psychosis, but need to be identified, include obsessive-compulsive disorder, affective disorders such as depression and anxiety disorders (including panic disorder and social phobia), eating disorders and medical conditions. The onset and course of these disorders and their relationship to the emergence of psychosis should be assessed.

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